Provider First Line Business Practice Location Address: 
3674 N RANCHO DR
    Provider Second Line Business Practice Location Address: 
SUITE 101
    Provider Business Practice Location Address City Name: 
LAS VEGAS
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89130-3110
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-396-2988
    Provider Business Practice Location Address Fax Number: 
510-281-6883
    Provider Enumeration Date: 
09/05/2011